How to Get IVF Covered by Insurance

Опубликовал Admin
8-04-2021, 07:10
Infertility can be stressful, and finding out your insurance doesn’t cover expensive procedures will only add to your anxiety. Unfortunately, only 15 U.S. states currently have laws requiring insurers to offer coverage for infertility. Most patients will need to make their case to their insurance company to get any portion of IVF covered. By choosing the most beneficial insurance plan, obtaining the necessary referrals, and fulfilling any testing requirements, you can increase your chances of getting IVF covered by your insurer.

Choosing the Right Insurance before Starting IVF

  1. Compare available plans with an employee benefits officer. Meet with a benefits specialist from your employer to discuss the different health plans available for you to select. They can help you compare deductibles and lifetime maximums for infertility coverage and IVF within available plans to choose the best plan for you.
    • If you have insurance through a spouse’s plan, prepare a list of questions about IVF and infertility coverage that your spouse can ask their benefits specialist.
    • If you have insurance through the Affordable Care Act, call their help line at 1-800-318-2596 to discuss your coverage options, including infertility benefits by plan in your state.
  2. Consult your doctor about your insurance options. Ask the insurance liaison at your doctor’s office which plan from those available will be best given the fertility tests you need. They can provide guidance about the relative costs of different procedures under the different plans.
    • If needed, set up a meeting in the office. You can bring in the materials provided to you by your employer comparing the coverage of the available plans.
  3. Pick a plan without a lifetime cap for infertility coverage. Opt for a plan with generous infertility benefits that covers as much of your potential IVF costs as possible. Even if your monthly premium is higher, it will likely not exceed the cost of uncovered IVF, which can cost between $15,000-$18,000 USD per fresh cycle, including medications.
  4. Select a more favorable insurance plan during open enrollment. Switch from an HMO to a PPO to give yourself more comprehensive and flexible infertility coverage. An annual window called open-enrollment allows you to switch insurance plans easily through your employer and select new coverage.
    • You may be able to switch coverage for other life events, such as getting married, even if they are outside the open-enrollment period.

Confirming Your Coverage and Getting a Referral

  1. Call your insurer for an assessment of your benefits. Look on the back of your insurance card, and call the phone number listed for members rather than providers. Ask to be connected with a benefits specialist who can explain the fertility benefits offered by your current health insurance.
    • Have a list of questions prepared before the phone call to ask your insurance provider. Some good questions to include are: What are the fertility benefits included in my plan? What is excluded? Are there age limits for infertility treatments? Does my plan cover fertility diagnosis procedures? And, is IVF covered by my plan?
    • Depending upon your infertility situation, you may have more specific questions regarding certain treatments, medications, and providers.
  2. Find out if you need a referral for a fertility assessment. Ask your benefits specialist if you need a referral before you can consider IVF. Most plans that require referrals necessitate that you to have an existing relationship with a primary care doctor who can connect you with an approved fertility specialist.
    • If you don’t have a primary care doctor, you will need to select one from a list of approved providers.
  3. Obtain a referral from your primary care doctor for a fertility specialist. Bring any required referral forms to an appointment with your primary care doctor. After discussing your infertility history, your primary care doctor can determine the most appropriate specialist that is in network for you for further testing. Provide these signed referrals to your insurance company for approval.
    • Allow some time for any referrals to be processed. Each referral can take up to 4 weeks to be approved by your insurance, and you may need multiple approvals if you end up needing multiple specialists.
    • Wait for approval before scheduling any specialist appointments.
  4. Ask your specialist to call your insurance after your first consultation. Make an appointment with your specialist after your referral has been approved. Ask the insurance liaison in your specialist’s office to call your insurer and find out the coverage of any diagnostic testing beyond your first appointment.
    • Most people have coverage for an initial consultation with a specialist, but you may need to meet a deductible before additional coverage kicks in.
    • Your insurance provider can give your specialist’s office a better idea of what is covered and what is not under your plan depending on the fertility tests your specialist want to run.

Demonstrating Your Need for IVF

  1. Complete a full fertility assessment. Get a comprehensive assessment of your fertility performed by a specialist to rule out any treatable conditions inhibiting conception. This is necessary whether your plan requires referrals for these tests or not. Nearly all insurance providers will require tests to illustrate your infertility before they will consider covering IVF.
    • Your insurance company can let you know which tests are required as part of your fertility assessment. Examples of common tests necessary before IVF can be considered are: an HSG or sono-HSG test, a semen analysis, a day 3 FSH test, and a Prolactin or TSH test.
  2. Pursue any treatment options your insurer requires before IVF. Find out which treatments, if any, your insurance plan requires before the insurer will approve IVF. Some plans may require intrauterine insemination or follicle-stimulating hormones, for example, before providing any IVF coverage.
    • In situations where your insurer requires the use of follicle-stimulating hormones, certain plans may cover treatments with one type of hormone and not another. Your insurer can provide clarity on situations in which they provide partial infertility coverage.
  3. Provide documentation of prior tests and treatments to your insurer. Get paperwork from your specialist(s) documenting all the tests and treatments you have completed as part of your fertility assessment. Send these to your insurance company for their records, and follow up to make sure they have been noted as complete in your medical profile.
  4. Make any lifestyle changes required by your insurer for IVF coverage. Quit smoking and make any other lifestyle changes your insurance plan requires before IVF can be considered. Even though your fertility assessment may show a need for IVF to conceive, your insurance company can halt your approval if you do not meet other health criteria they require.
  5. Get any preauthorization testing done. Ask your insurance company if there is any additional testing you need done before they can approve you for IVF. Depending upon your health, they may require hormone studies or uterine imaging, even if you’ve had these tests in the past.
    • Some insurers require these tests every 6 months for your IVF approval to remain in good standing.
  6. Appeal any denials for coverage. Ask your fertility specialist to write a letter on your behalf in support of your treatment plan. Fill out any appeals paperwork, and submit it to your insurer with the letter from your doctor. Try to be patient, as appeals can be a months-long process.
    • Just because you are denied for IVF coverage does not mean you cannot pursue IVF. You can proceed with your treatment plan, but you will be responsible for any uncovered expenses.
    • If you decide to pursue IVF using your own funds, you may be able to get reimbursed for eligible expenses if your insurer later approves your appeal. This varies by plan. Before pursuing IVF with your own money, ask your insurer about the possibility of future reimbursement in case your appeal is granted.


  • Only 5 states in the U.S mandate that insurers cover IVF in case of infertility. Those states are Illinois, Massachusetts, Rhode Island, Connecticut, and New Jersey. If you have pursued all other viable options, you could consider moving to one of these states for the purposes of treatment.
  • This article focuses on getting IVF covered by insurance in the United States. If you live outside the U.S., look into your local regulations and personal insurance policy to find out more about IVF coverage.
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